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HPV: time to get vaccinated?

What with talk of infections, cervical screening and now a vaccine, it's no wonder the message about HPV has become a game of Chinese whispers. Nursing in Practice reporter Nadine Woogara talks to Hammersmith Hospital nurse Louise Cadman about the new HPV vaccines, and whether or not we can soon wave goodbye to the dreaded smear

Nadine Woogara
Bsc(Hons) PgDip
Reporter
Nursing in Practice

Everybody who has ever had sex has a 70% lifetime risk of contracting human papillomavirus (HPV) at some point in their lives. But despite this, most women don't even know what it is. Once badmouthed as the disease of promiscuity, HPV is now better known as a cause of cervical cancer. There are over 100 types of HPV and 40 of these are usually transmitted through sexual contact.

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"HPV is a tricky infection because it can cause something as serious as cervical cancer, but for the vast majority who have it, they have no symptoms, no problems," says cancer nurse Louise Cadman. "It's difficult to try and inform people while trying to keep it in some kind of perspective." Of the women infected with HPV, fortunately very few go on to develop cervical cancer. "In the UK we only have fewer than 3,000 cases of cervical cancer diagnosed each year," says Louise. "It is actually a very small number that go on to have serious problems as a result of HPV."
This small number in the UK is not, however, mirrored around the world and is mainly due to our successful cervical cancer screening programme, which has been estimated to save about 4,000 lives every year. However, for the first time in 10 years the number of women invited who actually attend for their smear has dropped below 80%. The latest figures this year from the Department of Health show that on average, every week 1,300 fewer women aged between 25 and 29 attend a smear than in 1995. Of the 4.4 million women aged between 25 and 64 invited for cervical screening across England in the year of 2005/2006, one million did not accept their invitation.
"Research shows that younger women are concerned that it's going to be painful and embarrassing" said Louise. "For older women it is more a matter that they cannot juggle their lives easily to fit in a smear test. It just sits on everyone's 'to do' list."Louise thinks that the success of the cervical screening programme means that fewer women are familiar with cervical cancer or someone with this disease and so the cervical screening programme is, to an extent, a victim of its own success in terms of fewer women attending for cervical screening. What further impact could preventing HPV by vaccination before infection have on cervical cancer prevention?

HPV vaccines: what's on offer
At the moment there are two HPV vaccines on the market, Gardasil (Sanofi Pasteur) and Cervarix (GlaxoSmithKline). The vaccines are based on hollow virus-like particles that mimic HPV but do not contain HPV DNA. They protect women against the most important high-risk HPV types 16 and 18 that cause cervical cancer.
Both are designed to promote virus-neutralising antibody responses that prevent the initial HPV infection. The vaccines also confer some protection for women who already have HPV. For example, a woman may be infected with type 16 but vaccination can protect her against type 18 infection. Researchers are today working out how to create a therapeutic vaccine that can help women who already have HPV, but work is still in early stages.
The advent of a vaccine, however, doesn't mean curtains for the cervical smear. HPV types 16 and 18 account for more than 70% of cervical cancers, but this still leaves the remaining cancers that won't be prevented by the vaccine. "One would hope that as the science develops they would be able to add more HPV types to the vaccine, and therefore offer greater protection," says Louise. "But at the moment, you wouldn't be able to say to women you will never have to have a smear. I think it's the two working in conjunction that are going to be the most effective."

Target population 
Because the HPV vaccines are preventive it is suggested that they should be offered as a "presexual debut" to adolescents. The antibody response in young adolescents is stronger and this may result in longer-lasting immunity. "We are looking to vaccinate young adolescents before they start having sex. It wouldn't make a lot of sense to vaccinate a baby and then to have to vaccinate them 10 years later as we do not know yet how long the vaccine lasts," says Louise. So the likely age for HPV vaccination currently suggested is 12-13 years of age.
The focus at the moment is on vaccinating girls.  It may, however, be that in the future boys are also offered the vaccine.
It is inevitable, however, that parents will find fault with the HPV vaccine. Some may think that at 10 or 11, their children are too young to be offered the vaccine, and that it may encourage them to have sex prematurely. Others may not believe that their child is at risk. "I think if someone has a really strong objection or viewpoint you're not going to overcome their opinion," says Louise. "But I would hope that people could get the whole place of HPV into perspective. In that it's extremely common and that you don't have to be promiscuous to get it - you just have to be unlucky."

Dreaming a dream of a national HPV vaccination programme
Over the past few months the government has been making faint murmurings in agreement "in principle" with a national immunisation programme against HPV  for girls aged 12-13 years. If it goes ahead, cervical cancer cases are estimated to drop by 70%, but currently introduction of the vaccine is waiting on peer review and a cost-benefit analysis. If details of the programme are agreed upon, the vaccination could become routine for young girls as early as autumn next year.
Public Health Minister Caroline Flint has been quoted as saying: "It is great news that vaccines have been developed that protect women against this form of cancer, and I am delighted to announce that we intend, in principle, to introduce an HPV vaccine into the national immunisation programme."
Louise Cadman is also optimistic. "We're hopeful that it will come into place, but you can't predict government and government spending. I think there are many countries that have already adopted it, like Australia and America, so I think it would be difficult to be the country that didn't."
Louise adds that the vaccine is worth the wait,  saying: "I think anything that can prevent disease and move things forward is a very good thing, and the exciting thing is that we're talking about a vaccine that can prevent cancer."

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